Mean Tumor Length Research Articles

Feasibility, Safety, and Factors Predicting Completion of CROSS Protocol–Based Neoadjuvant Chemoradiotherapy for Esophageal Squamous Carcinoma: Experience from an Indian Tertiary Care Cancer Center

Background Neoadjuvant chemoradiotherapy (NACRT) using the ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) protocol has improved esophageal cancer outcomes. This study reports the real-world experience of the CROSS regimen for esophageal squamous cell carcinoma (ESCC) regarding its feasibility, safety, and predictors of treatment completion from an Indian tertiary center. Methodology A retrospective review was conducted for patients with ESCC receiving CROSS (radiation dose: 41.4 Gy) or a modified CROSS (mCROSS; radiation dose: 45 Gy) protocol NACRT between 2015 and 2022. We studied the treatment tolerability, factors predicting NACRT completion, and the effect of completion of its chemotherapy component on the pathological outcomes. Results Of the109 patients (68.8% males; mean age, 56 ± 9 years; Charlson's comorbidity index [CCI] >2, 19.3%; stage III–IVA, 58%; mean tumor length, 5.5 ± 2.1cm; CROSS, 70.6%; mCROSS, 29.4%), all except 4 completed radiotherapy but only 58 (53.2%) patients completed ≥4 cycles of chemotherapy. Forty-nine patients belonged to the “extended” CROSS trial inclusion criteria. Among the 60 patients who fulfilled the CROSS inclusion criteria, only 51.7% were able to complete ≥4 chemotherapy cycles. The commonest reason for noncompletion of chemotherapy was the occurrence of neutropenia (60.8%). Pretreatment hemoglobin (≥12 vs. <12 g%; odds ratio [OR]: 2.76; 95% confidence interval [CI]: 1.10–6.96; p = 0.031), a low CCI (≤2 vs. >2; OR: 2.98; 95% CI: 1.02–8.73; p = 0.047), and radiation therapy techniques (conformal vs. conventional; OR: 3.29; 95% CI: 1.14–9.50; p = 0.028) were associated with completion of chemotherapy (≥4 cycles). Although there was a trend toward improved R0 resection (95.7 vs. 91.4%), reduced node positivity (17.0 vs. 31.4%), and a high pCR (57.4 vs. 48.6%) in patients completing chemotherapy (≥4 cycles) compared with those not completing chemotherapy (<4 cycles), these differences were statistically nonsignificant. Conclusion In this study, ESCC patients receiving the CROSS protocol NACRT could complete their radiotherapy component, but a significant proportion exhibited poor chemotherapy tolerance. Neutropenia was a major factor limiting chemotherapy delivery, but anemia, high CCI, and conventional radiation techniques were also associated with noncompletion of chemotherapy. The omission of a few chemotherapy cycles had no significant effect on the pathological response; however, its impact on cancer survival requires further evaluation.

Single-incision Retroperitoneal Laparoscopic Resection of Adrenal Tumors in Children

BackgroundWe describe our experience with single-incision retroperitoneal laparoscopic (SIRL) for resection of adrenal tumors in pediatric patients and discuss the technique's clinical value. MethodsWe retrospectively analyzed clinical data of 27 pediatric patients who underwent SIRL between January 2020 and September 2023. Patients with tumors >5 cm in size and those requiring vascular skeletonization surgery or extensive lymph node dissection were excluded. Demographic, perioperative, and prognostic data were collected, and computed tomography (CT) and magnetic resonance imaging were used for preoperative tumor assessment. ResultsOf 27 patients, 16 were male and 11 were female; mean age 54 ± 45 months and mean body mass index 17.2 ± 3.6 kg/m2. Mean tumor length, width, and height were 4.1 ± 1.8 cm, 3.3 ± 2.1 cm, and 2.9 ± 1.7 cm, respectively. One patient experienced a diaphragmatic tear, three patients incurred peritoneal damage, and one patient developed postoperative renal artery injury, leading to thrombosis and renal atrophy. No surgery was converted to open surgery, and no intraoperative or postoperative blood transfusions were required. Operative time, blood loss, and postoperative dietary recovery time were satisfactory. No local recurrence or distant metastases were detected during the 6–48 months of follow-up involving outpatient and telephone assessments. ConclusionsApplication of SIRL in pediatric patients with adrenal tumors achieved favorable clinical outcomes with an effective, minimally invasive surgical option for treating children with adrenal tumors. This technique demands a high level of surgical expertise, specialized instruments and experienced surgeons. Our findings indicate that SIRL is safe and provides significant postoperative benefits in pediatric patients. Level of EvidenceLevel IV.

“WATCH AND WAIT” STRATEGY IN RECTAL CANCER PATIENTS WITH A COMPLETE CLINICAL RESPONSE AFTER NEOADJUVANT CHEMORADIATION THERAPY: A SINGLE-CENTER EXPERIENCE

Background. The non-operative management of rectal adenocarcinoma (RA) after neoadjuvant chemoradiation therapy (nCRT) has gained increasing attention. The “Watch and Wait” (“W&W”) strategy allows one to avoid surgery-related reduction in the quality of life due to permanent pelvic organ dysfunction or irreversible stoma. Still, the oncological safety of this strategy is under evaluation. Aim. To share a single-center experience of the “W&W” strategy. Materials and Methods. The retrospective analysis of 125 patients who received nCRT in 2016—2021 was performed. Patients who met the European Society for Medical Oncology (ESMO, 2017) criteria of clinical complete response (cCR) and received non-operative management were analyzed. Results. Ten patients (8%) were re-staged after nCRT as cCR and followed the “W&W” strategy. Patients’ characteristics: 7 female, 3 male; mean age 67.3 years. Tumor characteristics: pre-treatment N+ was present in 7 cases; G1 adenocarcinoma in a majority of cases; mean tumor distance from the anal verge — 5.85 cm; mean tumor circumference — 71%; mean tumor length — 3.87 cm. The mean follow-up time was 30 months. Local regrowth or/and distant metastases developed in 3 cases. The 2-year disease-free survival was 70%. Conclusions. Most of the patients following the “W&W” strategy have benefited. However, to reduce the number of relapses, it is necessary to perform a more careful selection of patients.

Dose Escalation by Intraluminal Brachytherapy in Cancer Esophagus – A Retrospective Audit

Introduction- Chemoradiation (CRT) in esophageal cancer as a definitive modality of treatment has shown an increasing trend of utilization over surgical modalities. Local failures after chemoradiotherapy have led to the concept of radiation dose escalation, but simultaneously it leads to the concerns of radiation related toxicities of strictures and fistulas. Considering this fact dose escalation with intraluminal brachytherapy seems and optimal option. The present study retrospectively analyzed the safety and efficacy of using ILBT as a boost after external beam radiotherapy.Materials and Methods- Records of patients with Esophageal Carcinoma (EC) registered in the radiotherapy department between December 2008 to June 2016 were retrospectivelyanalyzed. Data was collected on patient, tumor and treatment characteristics and patient outcomes. The toxicitieshematological or radiation-induced were documented. Theresponse assessment after treatment and survival parameters were analyzed. Univariate and multivariate analyses were done for survival parameters. Statistical significance was considered if p-value was less than 0.05.Results- A total of 69 patients were eligible for the present analysis. Male to female ratio 1.09:1, with median age of 60 years. The common primary side was the middle 1/3rd esophagus. The mean tumor length was 6.4cm and all patients had squamous cell carcinoma. EBRT dose of 59.4 Gy was received 94.2% of patients, 13 (18.8%) received ILRT radiotherapy with 6Gy in a single setting. The median concurrent chemotherapy administered were 5. Grade 3 and 4 acute hematological toxicities were seen in terms of anemia (7.2%), leucopenia (18.8%) and thrombocytopenia (1.4%). Stenosis was seen in 40.6% of patients among which only 13 patients required dilatation. Nine of the patients receiving intraluminal brachytherapy (ILBT) developed fistula. The compete response was better in ILBT group (84.61 vs 57.49%, p=0.07). The median overall survival for all patients was 15 months. Overall survival was increased in patients of ILBT group (41 months versus 12 months, p=0.005).Conclusion- ILBT has the advantage of high precision and avoidance of dose to critical structures which could be optimally used for dose escalation in patients of cancer esophagus.

Ultrasound-Guided Percutaneous Thermal Ablation of Hepatic Focal Nodular Hyperplasia--A Multicenter Retrospective Study.

Background and Aim: To evaluate the clinical effect of ultrasound (US)-guided percutaneous thermal ablation of hepatic focal nodular hyperplasia (FNH). Methods: A retrospective analysis of the clinical data of patients undergoing US-guided percutaneous thermal ablation of FNH from November 2008 to August 2021 at five medical centers in China was conducted. Results: A total of 53 patients were included (26 males and 27 females). The mean age was 35.1 ± 10.8 years. Sixty-five lesions (46 solitary cases and 7 cases with multiple lesions) were included, 70.8% (46/65) of which were located in the right liver lobe. The mean tumor length was 2.9 ± 1.5 cm. All patients successfully completed the ablation treatment. Immediate postoperative imaging showed that the primary technical success rate was 94.3% (50/53). Two patients underwent ablation 3 and 6 months after the primary ablation, and the secondary technical success rate was 100% (2/2). The incidence of complications was 3.8% (2/53). Imaging follow-up was conducted regularly after ablation, and no residual lesion enlargement or tumor recurrence was observed during the follow-up period. The technique efficacy rate was 98.1% (52/53). Conclusion: US-guided percutaneous thermal ablation is a safe and effective treatment for FNH of the liver.

Radical surgical management of perianal giant condyloma acuminatum of Buschke and Löwenstein: long-term results of 11 cases.

Perianal Buschke-Löwenstein tumor (BLT) is characterized by an exophytic cauliflower-like mass surrounding the perianal region. Its tendency to infiltrate the adjacent tissues, its massiveness, and its high recurrence rate cause difficulties in treatment. The aim of this study is to report our strategy with wide local excision and flap reconstruction for BLT. From November 2002 to June 2019, 11 patients (9 men) with a mean age of 33.45 years (range, 19-54 years) were operated on for BLT. All patients underwent wide local excision and V-Y flap reconstruction, supplemented with other flaps whenever needed. No additional modalities were used. Two patients had a history of anal intercourse while all patients were human immunodeficiency virus-negative. The mean tumor length was 15.54 ± 1.34 cm (range, 10-26 cm). Human papillomavirus 6 was the most common type identified. Partial wound dehiscence developed in 3 patients, while anal stenosis, mucosal ectropion, or local recurrence was not observed during the mean follow-up period of 50.45 ± 1.75 months (range, 10-196 months). In patients with perianal BLT, wide local excision and flap reconstruction result in a high healing rate without significant complications.

Time to review the role of intraluminal brachytherapy for dose escalation after concurrent chemoradiation in cancer esophagus: A retrospective audit.

e16054 Background: Intraluminal brachytherapy (ILBT) for dose escalation after concurrent chemoradiation (CRT) in cancer esophagus is not routinely practiced. This is particularly attributable to radiotherapy toxicity in terms of strictures and fistulas. Cancer esophagus has poor locoregional control and overall survival rates in comparison to head and neck cancers. Dose escalation may be an option to counteract the high failure rates. Methods: A retrospective analysis was conducted for esophageal cancer patients treated between 2008 to 2016 planned for radical CRT to a minimum dose of 59.4 Gy in 33 fractions along with concurrent cisplatin 35 mg/m2 and 5 FU 375 mg/m2 on weekly basis. Further, the patients who received dose escalation after external beam radiotherapy (EBRT) completion by ILBT to a dose of 6 Gy in a single fraction to the pre EBRT volume were also analysed. The patient, tumor, treatment characteristics along with response rates, survival outcomes, and toxicities were evaluated and compared between the two groups - the patients who received ILBT and those who did not. Statistical significance between variables was analysed with the Chi-Square or Fischer’s exact test and t-test. Survival analysis was done by Log-Rank test. The analysis was done on a worst-case scenario basis where the patients lost to follow-up were considered dead. Results: The total number of patients treated by CRT was 69, out of which 13 patients received ILBT for dose escalation. The median age was 60 years (Range - 40 to 80 years) and the male: female ratio was 1.09, mean tumor length was 6.4 ± 2.4 cms (Range-1.5-12 cms). The commonest tumor site was the middle third observed in 58% patients. The median EBRT dose was 59.4 Gy (Range- 9 to 63 Gy). The median concurrent chemotherapy cycles were 5. The median follow-up period was 15 months (range 1-100 months). In terms of complete response rates, there was a trend towards significant improvement in patients receiving ILBT compared to those receiving EBRT alone (84.61% versus 57.49%, p=0.07). Also, the overall survival (OS) was significantly higher in the ILBT group (45.31 months versus 19.20 months; p = 0.005). The other patient, tumor, and treatment characteristics analyzed showed no significant impact on OS. There was no significant difference in the incidence of strictures (p=0.206) and severity (p=0.764) of strictures amongst both the groups. Grade ≥3 late toxicity was reported in 10 patients (17.85%) receiving EBRT alone and in 3 patients (23.07%) receiving ILBT. None of the patients receiving ILBT developed a fistula. Conclusions: The present study reveals a dramatic increase in OS by dose escalation with ILBT. The limitations of the present study were a small sample size and a lesser number of patients in the ILBT group. Recapitulating the concept of ILBT to increase the local tumoricidal dose may improve the survival rates.

The in vivo tissue effect of endoscopic balloon‐based radiofrequency ablation in treating esophageal squamous cell neoplasia

Endoscopic radiofrequency ablation (RFA) is a rapidly evolving therapeutic modality for early flat esophageal squamous cell neoplasms (ESCNs). However, the invivo tissue effects of RFA on the esophageal wall are uncertain. We prospectively enrolled eight patients with flat-type early ESCNs who were treated with balloon-based RFA. We evaluated the invivo tissue effect on the esophagus using endoscopic ultrasound (EUS) and the histology of retrieved coagulum. The mean tumor length was 6.1 cm, and six of the eight patients achieved a complete response after primary RFA. Real-time evaluation of the tissue effect showed that the mucosa and submucosal layer were more edematous and thicker after RFA than before the procedure (mean 4.89 vs. 2.04 mm, p<.001), suggesting that the thermal effect of RFA may injure the submucosa. Histological evaluation of retrieved coagulum showed a severe cauterization (burning) effect with extensive cell necrosis; however, four cases had some residual viable neoplastic cells. Even though there were viable cells in the sloughed coagulum, half of the patients still achieved complete remission after RFA. Our findings suggest that the thermal effect of RFA may injure the submucosal layer and enable neoplastic epithelium to slough off without "burning."

Tu1389 CAN PROPHYLACTIC APC REDUCE DELAYED POST-PAPILLECTOMY BLEEDING? A PROSPECTIVE RANDOMIZED MULTICENTER TRIAL

Endoscopic post-papillectomy bleeding occurs in 3 to 20% of cases and delayed bleeding within one week is also problematic. However, there was no definite guideline or consensus for prevention or reduction of delayed post-papillectomy bleeding. Submucosal injection of dilute epinephrine before endoscopic papillectomy may not aid in reducing the risk of delayed bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to prevent or reduce delayed post-papillectomy bleeding. A prospective randomized study was performed at six tertiary referral centers in Korea. Patients with benign papillary tumors were enrolled from January 2015 to August 2017 and were randomized to either the prophylactic APC group or non-APC group. Endoscopic papillectomy was performed using a conventional snaring papillectomy method. Then, APC on the resection margin was performed in the prophylactic APC group. On the day after papillectomy, all patients underwent follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up with duodenoscopy at 1 month later. The main outcome measures were delayed (>24 h) post-papillectomy bleeding rate and remnant tissue ablation effects. In total, 48 patients underwent endoscopic papillectomy. Delayed bleeding rates in the prophylactic APC and non-APC groups were 33.3% (8/24) and 16.7% (4/24), respectively (p=0.336). Tumor persistence at 1 month did not differ between the two groups (12.5% vs. 8.3%, p=0.628). The mean tumor length and width were 11 and 12 mm in the prophylactic APC group, and 13.6 and 12.7 mm in the non-APC group. En-bloc resection rates in the prophylactic APC and non-APC groups were 83.3% (20/24) and 95.8% (23/24), respectively. Positive resection margin rates in the prophylactic APC and non-APC groups were 66.7% (16/24) and 33.3% (8/24), respectively (p=0.076). Post-procedure pancreatitis rates were 20.7% (5/24) in the prophylactic APC and 37.5% (9/24) in the non-APC groups, respectively (p=0.295). The severity of pancreatitis did not differ between the two groups. There were no procedure-related mortalities or serious complications. Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation. The prophylactic APC group seemed to have a higher tendency of delayed post-papillectomy bleeding without statistical difference and might be also ineffective on remnant tumor ablation during short-term follow-up.

Prognostic relevance of serial endoscopic ultrasound after chemoradiation in esophageal cancer.

The objective of this study is the feasibility of sequential endoscopic and endosonographic measurement of locoregional tumor load for the prediction of tumor recurrence in patients after neoadjuvant or definitive chemoradiotherapy, treated in curative intent for locally advanced esophageal carcinoma. In 67 patients with esophageal cancer, serial endoscopic ultrasound was performed before and after neoadjuvant (25) or definitive (42) chemoradiotherapy. Rate of complete endoscopic and endosonographic tumor response, reduction in tumor length or circumferential tumorous extension, maximal tumor thickness, lymph node size, and endosonographic uT- and uN-stage shift was measured. Results were correlated with tumor recurrence rate. After chemoradiotherapy, endosonography revealed a complete response of the primary tumor in 27 patients, and complete resolution of suspicious lymph nodes in 24 patients. According to uTN-stage, 43 patients showed a therapeutic response, with stage shift to a lower tumor stage. In patients with macroscopic residual disease, mean tumor thickness decreased from 13 to 9 mm, with nine patients presenting with a decrease of >50%. Mean tumor length decreased from 5.6 to 4.6 cm, with 10 patients showing a decrease of >50%. Mean lymph node size decreased from 14.5 to 12 mm, with four patients having a reduction in size of >50%. Tumor response was generally more pronounced after definitive than after neoadjuvant chemoradiotherapy. During follow-up, 33 patients developed a tumor recurrence. None of the endoscopic and endosonographic parameter analyzed was predictive for patient's prognosis, irrespective of the kind of chemoradiotherapy (neoadjuvant or definitive). Sequential measurement of locoregional tumor load with endoscopic ultrasound before and after chemoradiotherapy is not suitable for the prediction of tumor recurrence risk.

Épendymomes intramédullaires : étude rétrospective multicentrique française sur 221 cas

AimIntramedullary ependymomas (IE) are the most frequent intramedullary tumors in the adult population. The gold standard treatment is to obtain gross total removal without any new postoperative neurological deficit. The authors report the results of a multicenter series with a long-term follow-up and the analysis of clinical, radiological, surgical data as well as the complementary treatments. Materials and methodsA retrospective analysis of adult patients with IE operated on between January 1984 and December 2011 at 7 French centers (Bordeaux, Kremlin-Bicêtre, Lille, Lyon, Marseille, Montpellier, Nice, and Nîmes) was performed. The minimal follow-up was 12 months. The clinical evaluation was based on the McCormick classification in the pre and postoperative period at 3 months, 1 and 5 years. ResultsData of 221 adult patients with a pathologically confirmed diagnosis of IE were considered: 134 patients were treated at the Neurosurgical Department of Kremlin-Bicêtre Hospital, 26 were treated at Lille and 61 were treated in the southern region of France (Marseille, Bordeaux, Montpellier, and Lyon). The epidemiological analysis was performed on the entire cohort of patients, while follow-up considerations were made solely on the 134 patients managed at Kremlin-Bicêtre Hospital to obtain homogeneous data. A slight male prevalence was observed (59 % of cases), with an average age of 41.8 years at diagnosis. The mean age at first clinical manifestations was 39.6 years, thus the average duration of symptoms before the diagnosis was 29 months. Neuropathic pain and neurological deficit were the most revealing symptoms in 64 % and 32 % of cases respectively. The localization of the IE was basically cervical in 35.7 %, primarily thoracic in 25.8 % and cervico-thoracic in 22.2 %. The mean tumor length in the sagittal plan was 20.4mm (range 1 to 99mm). A cystic cavity was present in 76.5 % of cases while an intratumoral hemorrhage was detected in 30.3 % of cases. The rate of complete removal was performed in 79.2 % of cases when considering the whole cohort and in 91 % of cases treated at Bicêtre Hospital. In 95 % of cases a WHO grade I or II ependymoma was isolated and in 5 % of cases a WHO grade III. The McCormick scale (MCs) (Lou et al., 2012) [1] was used to rate the degree of preoperative functional impairment in 4 grades. In the immediate postoperative period a worsening of functional capacity was observed. Only 28.8 % of patients had MCs 1 in the immediate postoperative period; 34.8 % had MCs 2; 20.4 % had MCs 3 and 16 % had MCs 4. At 5 years of follow-up (101 patients) the frequencies of grades 1 and 2 were increased: 59 % of patients had MCs 1, 20.8 % had MCs 2, 10,9 % had MCs 3 and 9.3 % had MCs 4. The extension of the lesion on the sagittal plan calculated on the preoperative MRI, was the only predictive factor associated with the immediate postoperative outcome and the short-term follow-up (P=0.04), whereas the preoperative neurological status is the only predictive factor for long-term follow-up (P=0.005). ConclusionGross total removal remains the mainstay treatment for IE. Early surgery is indicated if the patient is symptomatic or the tumor increases in size. A postoperative regular follow-up is mandatory for at least 10 years due to the risk of recurrence. If a growing residue is detected, a second intervention is recommended without any adjuvant treatment if a WHO grade I lesion is confirmed by the pathological analysis. Complementary treatment should be reserved for high-grade ependymomas or in case of unresectable and progressive residue.

Endoscopic Submucosal Dissection of Superficial Esophageal Neoplasms Is Feasible and Not Riskier for Patients with Liver Cirrhosis.

BackgroundEsophageal endoscopic submucosal dissection (ESD) has rarely been reported for the treatment of cirrhotic patients.AimTo report the results of ESD treatment of superficial esophageal neoplasms (SENs) for cirrhotic patients.MethodsForty patients with 50 consecutive SENs undergoing 46 sessions of ESD were retrospectively reviewed. The cirrhotic group included eight patients (11 SENs) with liver cirrhosis consisting of six patients classified as Child-Pugh class A liver cirrhosis and two patients classified as class B liver cirrhosis. Four patients (6 SENs) had coexisting esophageal varices. Parameters were compared between the cirrhotic patients and the non-cirrhotic controls (32 patients, 39 SENs).ResultsPlatelet counts of the cirrhotic group were significantly lower, while international normalized ratio was significantly higher. When the cirrhotic group and non-cirrhotic group were compared, the mean tumor length (4 vs. 3.7 cm, p = 0.56) and median procedure time (15.1 vs. 11.5 min/cm2, p = 0.30) were similar. The en bloc resection rates were 81.8 and 89.7 % (p = 0.60). Within the cirrhotic group, both lesions without en bloc resection were patients with esophageal varices. The rates of submucosal disease for the cirrhotic group and non-cirrhotic groups were 54.5 and 25.6 % (p = 0.064), respectively, while the R0 resection rates were 77.8 and 94.3 % (p = 0.16), respectively. The two lesions without R0 resection in cirrhotic group had positive vertical but not horizontal margins due to submucosal invasion. Intraprocedural bleeding occurred more frequently in cirrhotic patients than non-cirrhotic patients (18.2 vs. 0 %, p = 0.045). None of the patients suffered from esophageal perforation, postoperative bleeding, or death that was related to the ESD.ConclusionEsophageal ESD seems to be safely and can be effectively performed on cirrhotic patients, particularly those without severe liver dysfunction.

Assessment of Tumor Size Before and After Palliative Endoscopic Spray Cryotherapy for Treatment of Dysphagia in Advanced Esophageal Cancer: A Pilot Study

Introduction: Endoscopic cryotherapy is increasingly used for the palliation of dysphagia (DP) from bulky esophageal tumors. Our prior research has shown endoscopic cryotherapy to be safe and effective for DP palliation in unresectable esophageal cancer. Although clinical improvements in DP have been documented, there is no evidence to demonstrate objective reduction in tumor size with this treatment modality. The goal of this pilot study was to objectively evaluate the change in the size of the primary esophageal tumor before and after treatment with cryotherapy. Methods: A retrospective consecutive case series of 7 patients with stage IV esophageal adenocarcinoma who received endoscopic cryotherapy for palliation of DP and had contrast enhanced Computerized Tomography (CT) before and after cryotherapy from May 2014 to October 2015. Each mucosal site was treated for 20-30 seconds for 2-3 cycles with at least 45 seconds between freezes to allow complete tissue thawing. Tumor size was assessed using the CT scans. The maximum length and thickness of the tumor was recorded in centimeters (cm). DP was measured using a 4-point Likert scale: 0, no DP; 1, DP to solids; 2, DP to semi-solids; 3, DP to liquids; 4, DP to own saliva. Wilcoxon signed rank test was used to evaluate change in tumor size and DP scores between pre- and post-cryotherapy. Results: Of 7 patients, 6 were males and 1 female. Mean age was 53.3 years. Among 7 patients, a total of 19 cryotherapy treatments were delivered (mean treatments per patient=2.7; range 2-4). All 7 patients also received systemic chemotherapy while undergoing cryotherapy. Six out of 7 patients demonstrated progression of the metastatic disease during this time period. The mean tumor length decreased from 4.4 cm pre-cryo to 3.2 cm post-cryo while the mean tumor thickness decreased from 1.4 cm pre-cryo to 1.2 cm post-cryo. Similarly, the mean DP score improved from 3.5 pre-cryo to 2.5 post-cryo. None of these findings was statistically significant owing to a very small sample size. None of the patients had any adverse effects. Conclusion: Our pilot study provides preliminary evidence of reduction in tumor size following endoscopic cryotherapy for palliation of DP in patients with advanced esophageal cancer. The reduction in tumor size was evident despite progression of distant metastatic disease in the majority of patients. Prospective studies with large sample sizes are needed to confirm this finding.

Endoscopic full-thickness resection with defect closure using clips and an endoloop for gastric subepithelial tumors arising from the muscularis propria

This retrospective study evaluated the safety and efficacy of endoscopic full-thickness resection (eFTR) with defect closure using clips and an endoloop for the treatment of gastric subepithelial tumors (SETs) arising from the muscularis propria (MP). From January 2009 to December 2012, 51 patients with gastric SETs arising from the MP underwent eFTR with defect closure using clips and an endoloop. The key steps were (1) several milliliters of mixture solution was injected into the submucosa after dots were marked around the tumor; (2) a cross incision was made in the mucosa to reveal the tumor; (3) subsequently, circumferential excavation was performed as deep as the muscularis propria, and full-thickness resection of the tumor was performed with an insulated-tip knife, including its underlying MP and serosa; (4) the gastric wall defect was closed with clips and an endoloop was then placed to fix and tighten all of the clips together. Successful complete resection by eFTR was achieved in 50 cases (98.0%). One case failed and was converted into a laparoscopic resection due to the tumor falling into the peritoneal cavity during the procedure. The mean procedure time was 52 min. No patients had severe complications, such as massive bleeding, delayed bleeding, peritonitis, or gastrointestinal tract leakage. The mean tumor length was 2.4 cm. Pathological diagnoses of the tumors were leiomyomas (21/51) and gastrointestinal stromal tumors (30/51). The median follow-up period after the procedure was 22.4 months (range 1-48 months), and no residual tumor or tumor recurrence was detected during the follow-up period. eFTR with defect closure with clips and an endoloop appears to be a safe and effective technique for the treatment of patients with gastric SETs originating from the MP, especially for those with extraluminal growth or adhesions to the MP.

Neoadjuvant chemoradiotherapy for esophageal/gastroesophageal carcinoma.

Esophageal/gastroesophageal junction (GEJ) adenocarcinoma is increasingly treated with trimodality therapy. We present our experience using carboplatin/paclitaxel and radiotherapy followed by surgery. Consecutive patients with distal esophageal/GEJ adenocarcinoma (≥T2 or N+) treated from July 2010 to October 2011 were identified. Treatment included neoadjuvant carboplatin/paclitaxel with concurrent radiotherapy (CRT) to 50.4 Gy using an IMRT technique and then Ivor Lewis esophagogastrectomy (ILE). PET/CT was performed prior to and after CRT. Patient/treatment characteristics and tumor response were analyzed. Over this timeframe, 16 patients completed trimodality therapy. All were male, median age of 60 years (45-72 years). All tumors were grade 2-3 with mean tumor length of 4.4 cm (1-9 cm). A median of 6 cycles (5-9 cycles) neoadjuvant carboplatin/paclitaxel were administered. Average time from diagnosis to CRT completion was 76 days (44-141 days) and 60 days (35-92 days) from CRT end to surgery. Neoadjuvant CRT was well tolerated with mean weight loss of 3.9 kg. All pts had R0 resections. No anastomotic leaks or perioperative mortality occurred. Mean hospital stay was 13 days (8-28 days). Pathologic complete response (pCR) was seen in 38% of patients, microscopic residual disease (isolated tumor cells or <2 mm) in 31%, and macroscopic residual disease remained in 31%. Mean SUV reduction was 41% (0-100%). Of 11 patients with ≥35% SUV decrease, 45% had pCR and 27% had microscopic residual disease. Three patients had signet ring features. Of these, 2 had no SUV reduction and all had gross residual disease, including the only patient with positive nodal disease. Trimodality therapy utilizing concurrent carboplatin/paclitaxel and radiotherapy to 50.4 Gy followed by surgery was well tolerated and resulted in significant pathologic complete response or minimal residual disease. Further investigation of predictive factors for response is needed to best tailor therapy in the management of esophageal/GEJ adenocarcinoma.

Neoadjuvant carboplatin/paclitaxel with concurrent radiotherapy followed by surgery for esophageal/gastroesophageal junction adenocarcinoma: A single-institution experience.

e14712 Background: Esophageal and gastroesophageal junction (GEJ) adenocarcinoma is increasingly treated with trimodality therapy. We present our experience using carboplatin/paclitaxel and radiotherapy followed by surgery. Methods: Consecutive patients with distal esophageal/GEJ adenocarcinoma (≥T2 or N+) treated from July 2010 to October 2011 were identified. All patients received neoadjuvant carboplatin/paclitaxel with concurrent radiotherapy (CRT) to 50.4 Gy using an IMRT technique and then Ivor Lewis esophagogastrectomy. PET/CT was performed prior to and after CRT. Patient/treatment characteristics and tumor response were analyzed. Results: Over this timeframe,17 patients completed trimodality therapy using this regimen. All were male with a median age of 59 years (45-72). All tumors were grade 2-3 adenocarcinoma with mean tumor length of 4.4 cm (1-9). A median of 6 cycles (5-9) neoadjuvant carboplatin/paclitaxel were administered, 3 patients received additional adjuvant therapy. Average time from diagnosis to CRT completion was 78 days (44-141) and from CRT end to surgery was 62 days (35-92). Neoadjuvant CRT was well tolerated with mean weight loss of 3.5 kg. All pts had R0 resections. No anastomotic leaks or perioperative mortality occurred. Mean hospital stay was 13.6 days (8-28). Pathologic complete response (pCR) was seen in 41% of patients, microscopic residual disease (isolated tumor cells or &lt;2mm) in 29%, and macroscopic residual disease remained in 29%. Mean SUV reduction was 41% (0-100). Of 12 patients with ≥35% SUV decrease, 50% had pCR and 25% had microscopic residual disease. Three patients had signet ring features; of these 2 had no SUV reduction and all had gross residual disease, including the only patient with pN disease. Conclusions: Trimodality therapyutilizing carboplatin/paclitaxel and CRT to 50.4 Gy IMRT followed by Ivor Lewis esophagogastrectomy was well tolerated and resulted in significant pathologic complete response or minimal residual disease. Further investigation of predictive factors for response is needed to best tailor therapy in the management of esophageal/GEJ adenocarcinoma.

Touchless gesture user interface for interactive image visualization in urological surgery

In the operating room (OR) a touchless interface is an ideal solution since it does not demand any physical contact and still can provide the necessary control features in a cleansed and sterilized environment. Using open-source software libraries and image processing techniques, we implemented a hand tracking and gesture recognition system based on the Kinect device that enables surgeon to successfully touchlessly navigate through the image in the intraoperative setting through a personal computer. We used the InVesalius software, which provides high-quality 3D reconstruction of medical images. Computed tomography data were intraoperatively fruitfully accessed through a simple and cheap solution in 4 tumor enucleations in 3 male patients in whom elective nephron-sparing surgeries were performed for small non-exophitic tumors. Mean tumor length was 2.7 cm (2.1, 2.7, 2.9 and 3.1 cm), and real-time ultrasound was not necessary for intraoperative identification in 3 of 4 endorenal tumors. All pathological reports revealed renal cell carcinoma, Fuhrman grade I, and negative inked surgical margins. No intra- or postoperative complication was reported. For the first time in the literature, a touchless user interface solution applying the Kinect device showed to be very efficient and enabled a low-cost and accurate control of the software InVesalius intraoperative, just using hand gestures. It can be used with any mouse-controlled software, opening an avenue for potential applications in many other areas, such as data visualization, augmented reality, accessibility, and robotics. The further validation and advancement of this technology are underway.

1515 TOUCHLESS GESTURE USER INTERFACE FOR INTERACTIVE IMAGE VISUALIZATION IN UROLOGICAL SURGERY

You have accessJournal of UrologyTechnology & Instruments: Surgical Education & Skills Assessment/Ureteroscopy II1 Apr 20121515 TOUCHLESS GESTURE USER INTERFACE FOR INTERACTIVE IMAGE VISUALIZATION IN UROLOGICAL SURGERY Guilherme Ruppert, Leonardo Reis, Paulo Amorim, Tiago Moraes, and Jorge Silva Guilherme RuppertGuilherme Ruppert Campinas, Brazil More articles by this author , Leonardo ReisLeonardo Reis Campinas, Brazil More articles by this author , Paulo AmorimPaulo Amorim Campinas, Brazil More articles by this author , Tiago MoraesTiago Moraes Campinas, Brazil More articles by this author , and Jorge SilvaJorge Silva Campinas, Brazil More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1282AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In the operating room a touchless interface is an ideal solution since it does not demand any physical contact and still can provide the necessary control features in a cleansed and sterilized environment. METHODS Using open-source software libraries and image processing techniques, we implemented a hand tracking and gesture recognition system based on the Kinect device that enables surgeon to successfully navigate through the image in the intraoperative setting. We used the InVesalius software, which provides high-quality 3D reconstruction of medical images. The hand of the user is tracked and the corresponding position is used to move the mouse pointer and button clicks events are also virtually generated. RESULTS Nephron-sparing surgery can be facilitated by using intra-operative hand gestures to provide touchless control of 3D medical imaging software. Computed tomography data from patients with renal masses were fruitfully accessed during surgery through a simple and cheap solution. The model was easily transferred to a personal computer, allowing the surgeon to touchlessly navigate through the 3D images in the intraoperative setting. We have utilized the proposed solution in 3 tumor enucleations in 2 male patients in whom elective nephron sparing surgery was performed for small non-exophitic tumors. Mean tumor length was 2.7 cm (2.1, 2.9 and 3.1 cm) and real-time ultrasound was not necessary in 2 tumors. All surgeries were guided by image review through gesture interface during the procedure, allowing anatomical support based on the 3D imaging previously obtained by CT scan. All pathological reports revealed renal cell carcinoma, Furhman grade I, and negative inked surgical margins. CONCLUSIONS The solution was successfully used intraoperative and can be used with any mouse-controlled software. This is an important step in bringing technology to the operating room to assist the surgeon directly, opening an avenue for potential applications in many other areas, such as: data visualization, augmented reality, accessibility and robotics. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e613-e614 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Guilherme Ruppert Campinas, Brazil More articles by this author Leonardo Reis Campinas, Brazil More articles by this author Paulo Amorim Campinas, Brazil More articles by this author Tiago Moraes Campinas, Brazil More articles by this author Jorge Silva Campinas, Brazil More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Radiosurgery for Para-IAC Meningiomas: The Effect of Radiation Dose to the Cochlea on Hearing Outcome

This study was performed to assess the radiosurgical results of meningiomas extending into the internal acoustic canal (para-IAC meningiomas), with a particular focus on the effect of radiation dose to the cochlea on hearing outcome. A total of 50 patients who underwent radiosurgery for para-IAC meningiomas between 1998 and 2009, which were followed for 2 years, were enrolled. The mean age was 55.8 years (range, 15-75). The mean tumor volume was 6.1 cm(3) (range, 1.0-19.0), the mean tumor length in the IAC was 6.9 mm (range, 1.3-13.3), and the mean prescribed marginal dose was 13.1 Gy (range, 10-15) at an isodose line of 50%. The mean follow-up duration was 46 months (range, 24-122). Eight (16.0%) patients had nonserviceable hearing at the time of surgery. At the last follow-up, the tumor control rate was 94%; unchanged in 17 patients, decreased in 30 patients, and increased in 3 patients. Among 42 patients with serviceable hearing at the time of radiosurgery, it was preserved in 41 (97.6%) patients at the last follow-up. The maximal and mean radiation doses to the cochleae of these 41 patients were 5.8 Gy ± 0.3 (range, 3.1-11.5) and 4.3 Gy ± 0.2 (range, 2.2-7.5), respectively. The maximal dose to the cochlea of the patient who lost hearing after radiosurgery was 4.7 Gy. The radiation dose to the cochlea may have the minimal toxic effect on the hearing outcome in patients who undergo radiosurgery for para-IAC meningiomas.

Detailed biopsy pathologic features as predictive factors for initial reclassification in prostate cancer patients eligible for active surveillance

ObjectiveTo evaluate the impact of detailed biopsy characteristics such as positive cores location or multifocality on the risk of initial reclassification in prostate cancer (CaP) patients eligible for active surveillance (AS). Materials and methodsWe reviewed data from 300 consecutive men eligible for AS (PSA ≤ 10 ng/ml, clinical stage T1c, Gleason score ≤6, <3 positive cores, extent of cancer in any core < 50%) who have undergone a radical prostatectomy (RP). Reclassification was defined as upstaged disease and/or upgraded disease in RP specimens. ResultsBiopsy features showed 36% of CaP involving 2 cores and a mean total tumor length of 2.63 mm. The 2 most frequently positive sites were base and apex. Mean total tumor length was significantly associated with upgraded disease (P = 0.025). In a multivariate model taking into account PSA, PSAD, number of positive cores and total tumor length, a total tumor length > 5 mm were independently predictor for a upgraded disease (OR 1.93, P = 0.046). The number, the multifocality and the bilaterality of positive cores were not associated with reclassification. Upgraded disease was significantly less reported in case of positivity at midline zone compared with positivity at base, apex, or transition zone (P = 0.013). ConclusionsDetailed biopsy data provide additional information on the initial risk of reclassification in AS patients. Patients having a total tumor length < 5 mm and positive cores at midline zone are more likely to have favorable pathologic characteristics at diagnosis. These variables can be used for selection and monitoring improvement in AS programs.